USLegal Forms USLegal Forms

Personal Representative Request Form

 Personal Representative Request Form
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State:
Multi-State
Control #:
US-3578
Instant Download
$19.95
Mail Paper Copy
$25.95
Completed Sample Available at Checkout
Available formats: Adobe PDF

Description

This form is used by a health plan to identify a representative of a subscriber who has legal authority to make health care decisions for the subscriber, such as a guardian, person appointed in a power of attorney, or other documented authority.

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